Medical Journal Houston Vol. 11, Issue 4, July 2014

Legal Affairs: OIG expresses suspension of arrangements between labs and physicians, see page 2

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The Leading Source for Healthcare Business News
July 2014 • Volume 11, Issue 4 • $3.50

Innovation in patient safety and quality
INSIDE
▼
EmbryoScope
see page 14

INDEX
▼
Legal Affairs......................2
Breaking Ground..............3
Integrative Medicine.........4
THA.................................5
Moving On Up.................6
Hospital
Headlines.........................7
Physicians Forum............9

Mindful flying
see page 4

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By Angela A. Shippy, M.D.,
Chief Quality Officer, Memorial
Hermann Health System
If you ask any healthcare provider if the care
they deliver is safe, they will undoubtedly
answer yes! There is never an intention to
do harm; however, patients are harmed in
healthcare facilities every day.
In 1999 and 2001, the Institute of Medicine
provided a call to action and a road map
to reduce errors and provide safer care to
patients in its widely read reports, To Err Is
Human: Building A Safer Health System
and Crossing The Quality Chasm: A New
Health System For The 21st Century. Over
the last 15 years, these two reports have been
quoted countless times and improvements
throughout the healthcare industry have
been made. But, clearly more can be done.
In 2006, Memorial Hermann Health
System, the largest not-for-profit hospital
system in Southeast Texas with 12 hospitals
and 21,000 employees, embarked on a highreliability journey by applying principles
embraced by high-reliability organizations.
High-reliability organizations, such as
commercial airlines and nuclear aircraft
carriers, are able to avoid preventable
adverse events in environments where
accidents could be expected because of risk
and complexity.
By making patient safety a core value,
Memorial
Hermann
underwent
a
transformation that started with our Board
and included every employee - clinical,
nutrition, clerical, environmental service,
maintenance, and volunteer. This $18
million dollar commitment prepared all staff
and employed physicians with safety culture
training. In addition, physician alignment
strategies including clinical integration
and clinical program committees were
strengthened to further support this effort.

With
an
Elective Delivery.
expectation of 100
percent compliance
The next step
with
evidencefor
Memorial
based
quality
Hermann in this
measures and a zero
transformation will
percent incidence
be to ensure these
of patient harm
better
processes
in all aspects of
are truly hardwired
patient care, a
into our system
uniform approach
and to translate
to
performance
them to sustained
improvement called
improved outcomes
Robust
Process
for patients. How
I m p r o v e m e n t™
do we get there?
(RPI)
was
established.
RPI
Use
RPI
as
includes Six Sigma,
our
disciplined
Lean, and change
approach
for
management
to
performance
solve
difficult
improvement
safety and quality
p r o m o t i n g
problems,
and
sta ndardization
encourages experts
and
decreased
closest
to
the
variation,
which
bedside to lead
results in better
performance
outcomes
and
Angela Shippy, M.D.
improvement
improved efficiency.
processes in order
to promote integration and standardization Eliminate failures in basic delivery of care
across the system.
This methodology by ensuring timely evaluation, improving
supports transparency of information direct communication among providers, and
vertically across the organization; allowing rapidly escalating and resolving identified
staff to access data and conduct “just-in- opportunities.
time” two-provider (“double”) checks,
supporting informed decision making, and Remain focused on the patient while
enhancing solution design.
adopting the principles of high reliability as
we continue to be a healthcare system that
This initiative resulted
delivers safe, quality
in significant zerocare while avoiding
harm milestones and
preventable errors.
the establishment of
a new High Reliability
“Quality is never an
Certified
Zero
accident; it is always
Award to celebrate a
the result of high
hospital’s successful
intention,
sincere
prevention of harmful
effort,
intelligent
events and adverse
direction
and
outcomes for 12 or
skillful
execution;
more
consecutive
it represents the
months. Since 2011,
wise choice of many
more than 114 awards
alternatives.” ~ Medal
have been presented to Memorial Hermann of Honor Recipient William A. Foster
hospitals in the categories of Central Line–
Associated Bloodstream Infection, Catheter This quote is right on target as it succinctly
Associated Urinary Tract Infection, demonstrates that we must be deliberate
Ventilator-Associated Pneumonia, Retained in our quest to provide the best healthcare
Foreign Object, Iatrogenic Pneumothorax, for patients and to ensure we have the best
Accidental Puncture and Laceration, processes and practices in place to eliminate
Pressure Ulcers Stage III & IV, Birth the opportunities for human error. t
Trauma, Serious Safety Events, and Early

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